Was the COVID pandemic suppressing the outbreak of scarlet fever in the United Kingdom?: Correspondence
Authors: Qamar Sultana, Vibhor Agrawal, Vikash Jaiswal, Aroop Mohanty, Ranjit Sah
Journal: International Journal of Surgery (2023)

Highlights According to WHO, Streptococcus pyogenes causes 500 000 deaths across the globe every year. The pharyngitis infection can spread and cause sinusitis, otitis media, and meningitis when left untreated. Acute rheumatic fever is a complication that occurs as an immune response to pharyngitis, causing high fevers, swelling and pain in the joints, cutaneous manifestations, chorea, and valvular dysfunction of heart valves. Dear Editor, Lancefield Group A Streptococcus (GAS), simply referred to as Group A Strep or Streptococcus pyogenes is found in the throat, is a part of normal skin flora, and is omnipresent in the environment, making it one of the most often encountered bacteria. It is a gram-positive coccus with multiple subtypes owing to the variability of the 'M' protein on its surface. GAS is the root of a spectrum of pathologies ranging from impetigo, erysipelas, cellulitis, and acute pharyngitis to invasive necrotizing fasciitis and toxic shock syndrome. The term scarlet fever is used in cases where a papular and blanching rash makes the skin feel like 'sandpaper,' is associated with streptococcal pharyngitis and is more often seen among children. The rash occurs due to erythrogenic toxin on the 2–3rd day and involves the trunk, groin, underarms, and face sparing the circumoral area but does not involve the soles and the palms. Scarlet fever symptomatology also includes sore throat, pain with swallowing, fever, enlargement of cervical lymph nodes, and a white coating on the tongue, which, when wanes, gives the tongue a strawberry-like appearance. The infection is contagious in that it spreads via contact with infected mucosal secretion or through an infected wound1,2. According to WHO, S. pyogenes causes 500 000 deaths across the globe every year3. Scarlet fever usually rises in the winter, in colder temperatures; however, we want to highlight that there has been a significant untimely increase in the number of cases in the United Kingdom. Based on data from UK Health Security Agency (UKHSA), in the past, there had been a similar trend of rise in the number of cases during the scarlet fever season for the years 2017–2018, the seasons being considered from the 37th week of the present year to the 36th week of the following year. In all, 30 768 notifications of scarlet fever were recorded in the entire time frame of the season. The comparison of the current 2022–2023 season with the previous seasons, including the 2017–2018 season, is elaborated in the graph (Fig. 1a), with the figures being alarmingly higher in the current season within a short span of time4,5.Figure 1: (a) A semilogarithmic representation of the comparison of the number of notifications of scarlet fever received from England in the past five seasons (data available from UK Health Security Agency, for recent weeks of 2022–2023 may change as further notifications are received). (b) A geospatial heatmap depicting the burden of disease in different regions of England and Wales for the week ending 18 December 2022 (data available from UK Health Security Agency).Since the infection spreads through cough, sneezing, and contact with the wound of an infected person, transmission in closed groups like classrooms and nurseries is not difficult2. Figure 1b represents the data of week 50 available from UKHSA, depicting what the caseload looks like in England and Wales5. The unbefitting rise is attributed to the aftereffect of the break of coronavirus disease 2019 precautions, including social distancing norms and isolation4. It is also the result of the lower levels of immunity following lockdowns in the younger populations6. An increase in respiratory viruses and the number of bacteria circulating in the environment also contribute to the rise. However, there is no confirmation stating the circulation of a gene sequence, antibiotic resistance, or a newer strain3,7. Scarlet fever has an excellent prognosis when promptly treated with antibiotics with penicillin and amoxicillin as the first-line treatment. The pharyngitis infection can spread and cause sinusitis, otitis media, and meningitis when left untreated2. Acute rheumatic fever is a complication that occurs as an immune response to pharyngitis, causing high fevers, swelling and pain in the joints, cutaneous manifestations, chorea, and valvular dysfunction of heart valves1. Further spread and bacteremia lead to necrotizing pneumonia, necrotizing fasciitis, and toxic shock syndrome, causing debilitating pain, systemic symptoms, and sepsis requiring aggressive treatment with intravenous antibiotics1,7. To achieve mitigation of such invasive complications, it is advised by the UKHSA to look for signs of worsening disease in children, including severe aches, higher unresolving fevers, severe local tenderness of muscle with increased redness, swelling, and pain at the site of the wound, vomiting, and diarrhea. In the younger population, irritability, tiredness, signs of dehydration, appetite changes, and cyanosis should raise a concern4. In terms of public health impact, during the coronavirus disease 2019 pandemic measures, infections were relatively controlled, although GAS cases have been rising in Britain since 20167. This is evident from the increased incidence of these infections compared to pre-pandemic times8. The fear of the infection has led to a decline in the obtainability and availability of age-appropriate antibiotics. The cost of the needed medications is reported to have gone up, adding to the uncertainty faced by the people in availing them. Scarlet fever is a clinical diagnosis provided the patients are promptly brought to the physician's care8. Throat culture, which is specific but takes days, and a nonspecific rapid test also aid in diagnosis2. It is a strip test done by passing a cotton swab over the back of the throat. Due to the feasibility and rapid display of results, the test kits have faced the verge of being sold out in the United Kingdom. Some are sold at higher prices and not available immediately, leading to panic buying among the population8. The WHO has advocated for all other countries to be vigilant to the rise of invasive group A strep infections. It has advised clinicians to maintain suspicion of GAS while assessing patients, to treat close contacts, and to report clustering of cases, if any, to the authorities in order to address the concern3. Personal hygiene and hand hygiene are simple and the most efficient way to break the chain of transmission and thus lower the disease burden3. It is recommended to wash hands with warm water for about 20 s and to limit the spread of respiratory secretions using tissues4,7. The infection can spread through asymptomatic individuals, but the risk of spread rises in symptomatic patients. A patient with a mild illness does not spread the disease after 24 hours of prompt antibiotic treatment. Thus, refraining from attending gatherings like workplaces and schools for a day after the commencement of treatment will limit transmission2,3. Since it is possible to misdiagnose scarlet fever due to the similar rash in other conditions, including measles and chickenpox, being on the lookout for a differential diagnosis will limit the confusion. This also brings attention to the fact that patients and physicians should not underestimate the importance of regular vaccines and flu shots during this season to avoid an increment in the coexistence of multiple health concerns2. Ethical approval Not required. Sources of funding No funding was received. Author contribution Q.S., V.A., and V.J. designed and drew the original draft; A.M. and R.S. review the literature and critically edited the manuscript. All authors read and approved the final manuscript. Conflicts of interest disclosure None declared by the authors. Research registration unique identifying number (UIN) None Guarantor Ranjit Sah. Data availability All data are included in the manuscript.